IPA Bulletin
Recent Advances

Sex, Violence and Loneliness
Wendy Moyle

A number of recent reports have focused on important issues in late life that are less frequently considered. One recent publication reviewed the important issue of violence experienced by staff caring for people with dementia in nursing homes. Another addresses the importance of better understanding the phenomenon of loneliness experienced by persons with early stage dementia and their carers. Finally, authors have recently summarized the literature relating to the expression of sexuality in the nursing home. (WM)

Sexuality in nursing homes
A European study reviewed the literature on factors that influence the expression of sexuality by older people living in nursing homes. A search of the period 1996 -2009 identified 40 papers that met the study inclusion criteria. The majority of this literature was from the US and was readily classified into four broad thematic areas: sexuality and ageing, expression of sexuality, attitudes of staff, and sexuality in dementia. A number of key issues were identified in this literature. First, the lack of recognition of sexual diversity in nursing homes often results in groups such as gay and lesbian people not disclosing their identity to staff, for fear of the consequences. Second, the nursing home environment, including a lack of privacy and staff attitudes, strongly influences residents’ opportunity to engage in sexual activity. Third, the need to protect residents who do not have the capacity to consent to sexual activity creates challenges for nursing staff. The authors suggest that decision making tools can help staff resolve such challenging issues, while improving residents’ quality of life, protecting their privacy and dignity, respecting autonomy, and reducing anti-discriminatory behaviour.

Elias & Ryan. The factors that influence expressions of sexuality by older people in care homes. J Clin Nrs 2011, 20, 1668-1676.

Loneliness and Dementia
This descriptive exploratory qualitative study, undertaken in Australia, aimed to explore the perceptions of loneliness according to people with early-stage dementia living in community and long-term care and also the views of their family carers. Seventy people with a diagnosis of probable dementia and 73 family carers were interviewed. Four themes were identified: (i) staying connected to others – participants revealed an association between the absence (and maintenance) of meaningful relationships and the experience of loneliness (ii) losing the ability to socially engage – dementia symptoms such as a reduced ability to contribute to conversations and to recognise faces or remember names helped to limit relationships (iii) experiencing loneliness – loneliness was intensified by other people’s understanding of dementia and their ability or inability, or desire to interact with the person with dementia (iv) overcoming loneliness – strategies such as keeping busy and remaining occupied assisted in reducing feelings of loneliness.

There was an assumption among carers that social isolation was the cause of loneliness. Often in such reports, the voice of the person with dementia was not being heard and was reduced by the belief that the carer knows what is “best” for the person. Both the carer and person with dementia discussed depression as the cause of loneliness and suicidal ideation. The findings emphasise the familiar human relationship, as well as an understanding of the person with dementia pre-morbid social tendency as being keys to reducing feelings of loneliness in people with dementia. Furthermore, the findings highlight the importance of identifying and treating depression in both the person with dementia and carers.

Moyle et al. Dementia and loneliness: an Australian perspective. J Clin Nrs 2011, 20, 1445-1453.

Dementia and Violence
This European paper provides a critical review of literature related to violence experienced by staff as a result of care of people with dementia in nursing homes. Databases using relevant MeSH headings were searched for primary research covering the period 1996-2007. The search identified 14 papers that met the study inclusion criteria. The authors concluded that while violence against staff in psychiatric settings has been well-documented, the same level of interest has not been shown in nursing home staff and, in particular, in staff caring for people with dementia. The review describes the psychological trauma suffered by staff when they experience violence and they argue against violence being accepted as part of the job. Some of the key findings include that younger staff experience higher incidence of exposure to violence compared to older staff. This was attributed to less experience and therefore younger staff having fewer coping strategies. In addition, staff exhaustion was attributed to residents’ aggressive behaviour and to staff perception of coping or personal self-efficacy. The authors conclude that staff under stress will focus on completion of tasks and this will reduce their ability to problem solve or to consider strategies to prevent and manage the incidence of violence.

Scott et al. Perceptions and implications of violence from care home residents with dementia: a review and commentary. Int J Older People Nrs 2011, 6, 110-122.

Major Depression
Mark Rapoport

Much attention in recent years has been given to the refractory nature of depressive illness in the elderly as well as associations between executive dysfunction and major depression among older adult. Two recent reports shed light on these aspects of major depression in the elderly. A meta-analysis systematically examining the relationship of cognitive impairments to antidepressant outcome in the elderly posed questions about the specific role of executive dysfunction in treatment outcome, beyond impairment in other cognitive domains, and an analysis of 3 pooled clinical trials demonstrated a promising antidepressant augmentation strategy using aripiprazole, at least in middle-aged adults. (MR)

Metaanalysis of Executive Dysfunction and Response to Antidepressants in the Elderly. Investigators from Adelaide, Australia conducted a systematic review and meta-analysis to investigate the impact of executive dysfunction on response to antidepressants in the elderly. They identified 17 publications meeting their search criteria, and found that five of the thirty cognitive tests used discriminated between those who responded to medication and those who did not. Of these 5 tests, only the initiation-perseveration subtest of the Mattis Dementia Rating Scale (DRS-IP) provided a measure of executive functioning. Of 9 executive functioning tests examined, only the DRS-IP discriminated between responders and non-responders, and this test only correctly classified 43% of patients. While this meta-analysis challenges conceptions of the specific role of executive dysfunction in predicting antidepressant non-response in the elderly, the authors point out that this must be distinguished from the etiological theory of frontal-subcortical disruption associated with depression, and that limitations of small numbers of studies and heterogeneity lead to ongoing questions in this area.

McLennan, S. & Mathias, J. The depression-executive dysfunction syndrome and response to antidepressants: a meta-analytic review. Int J Geriatr Psychiatry 2010; 25, 933-944.

Age-Stratified Pooled Analysis of Antidepressants Augmented by Aripiprazole. Steffens et al reported on a pooled analysis of 3 clinical trials in which patients with major depressive disorder underwent 8 weeks of antidepressant treatment followed by a 6 week randomized double-blind trial. In the 6 week phase, subjects were randomized to continue their antidepressant without dose adjustment, either adding placebo or aripiprazole 2-20mg per day. Change in the Montgomery Asberg Depression Rating Scale was the primary outcome. They divided their sample into an “older group” of 409 patients who ranged in age from 50 to 67 years, including only 3 patients over the age of 65. Most of these “older” subjects completed the randomized trial (87.8%), with no differences between groups. A modest effect size of 0.44 was reported with a 3.6 point difference in MADRS scores at 12 weeks, favoring the aripiprazole group, and a NNT of 7 for remission and 7 for response in the “older” group. None of the drug vs. placebo changes differed from the “younger” group’s changes. Discontinuation for side effects occurred in 4(2%) of the placebo group and 12 (5.7% of the drug group), and the most common adverse effects were akathisia, restlessness, insomnia and somnolence. More research is needed into the effectiveness and safety of this augmentation strategy with participants who are genuinely elderly, as they would likely be more vulnerable to such adverse effects.

Steffens, D.C. et al Efficacy and safety of adjunctive aripiprazole in major depressive disorder in older patients: a pooled subpopulation analysis Int J Ger Psychiatry 2011; 26: 564-572


Reprinted from IPA Bulletin, Volume 28, Number 2